L’exercice de la médecine générale en Palestine : influences des contraintes en territoires occupés

Le contexte d’occupation et de morcellement du territoire palestinien interroge sur l’organisation du système de santé et notamment de la médecine de première ligne. Est-ce que le contexte géopolitique est à l’origine de spécificités et/ou de variations d’exercice ? Nous avons étudié la pratique des médecins généralistes en Cisjordanie en identifiant les facteurs extérieurs d’influence de cette pratique. Une enquête de terrain (du 03 au 16 mars puis du 01 juillet au 31 août 2014) s’est appuyée sur une approche qualitative en réalisant des entretiens semi-structurés avec des médecins généralistes. Le contexte géopolitique, économique et structurel de la Palestine impacte leur exercice professionnel : les médecins sont isolés sur le territoire et dans le système de santé. Ils assurent des missions communes en soins de premier recours mais ont des difficultés pour répondre efficacement aux problèmes de santé des palestiniens notamment pour optimiser la prise en charge des maladies chroniques. Le développement de la médecine de famille en Palestine doit s’appuyer sur l’expérience des médecins généralistes et prendre en compte leurs conditions d’exercice. This paper questions health system organization, and especially first line care, given the context of occupation and fragmentation of the Palestinian territory. It asks whether the geopolitical context is the source of specific changes? We studied the activities of general practitioners (GPs) in the West Bank by identifying external factors which influence their practice. Methods A field survey (3-16 March and 01 July-31 August 2014) employed a qualitative approach by conducting semi-structured interviews with GPs. Physicians had to have obtained the Bachelor Degree of Medicine to practice medicine in Palestine (no family medicine speciality is required). They had to work in primary health care and the four main types of health provider were represented (Ministry of Health, UNRWA, NGOs and the private sector). Various health actors were also interviewed. Data analysis (figure 1) was based on the method described by Miles and Huberman (2003). In total, 35 interviews were conducted, 11 during the first period of the field survey and 24 during the second period. 23 GPs were interviewed (1 GP was interviewed at each period). The mains geographical and demographic characteristics of their places of practice are set out in the table I. Their places of exercise are represented on the map 1 Results Palestinian GPs integrate the psychological and environmental aspects of their patients’ experience. They provide joint missions: community-based and first line care, resolution of all undifferentiated health problems, prevention, and health education. The occupation of the territory isolates populations and prevents any territorial continuity. The governorates are fragmented and the health care system cannot develop homogeneously on the territory since institutions can be implanted only in area A or B defined by the Oslo Accords (urban hubs and their close suburbs). The geopolitical, economic and structural context of Palestine impacts their professional practice: physicians are isolated on the territory and in the health system. Health resources are difficult to access: they are not available in all governorates and the coordination between health providers is insufficient to promote community-based care. Primary care physicians respond with difficulty to the health problems of Palestinians given their limited use collective and complementary practices and their missing link with the secondary sector (which exists but is hardly accessible). The permanence and continuity of care are unpredictable as they depend on physicians and patients travelling to facilities; they are often forced by the checkpoints regime and other obstruction means on Palestinian roads. The comings and goings of patients from one health care provider to another on the territory also complicate their aftercare in the long term and the continuity of care. The instability of the situation, at the root of armed conflicts or altercations, also brings GPs to heal wounds “of war”. Discussion and Conclusion Our study shows that GPs practice is strongly constrained by the Palestinian geopolitical context and the health care access is inseparable from the territorial issue. Since 2014, family medicine is growing in Palestine with the support of WHO and other foreign institutions. A homogeneous discipline in primary care, would promote a fair access to quality health care for Palestinians. The development of the discipline should take into account the practice conditions of GPs in order to settle in primary care. The occupation of the territory, the instability of the situation and the absence of a Palestinian state are among the factors behind a specific type of practice of family medicine in this part of the world.